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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT ' 1601 E. HAZE T ON AVE., STOCKTON, CA Telephone 52091 466-6781 �E PERMIT EXPIRES I'YEAR FROM DATE ISSUED '��ti"" (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for weupump and the Rules and Regulations of the San Joaquin Local Health District. Job Address _I'I`IYJ�- City �7Lot Size PM Owner's Nt"7N=A Address m Phone fee Contractorddress ! /.f /_��! License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION �14efM4 STEM REPAIR L3 OTHER El DISTANCE TO NEAREST: SEPTIC TANK# SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom -Manteca Dia. of Well Excavation Dia. of Well Casing Domestic/Private ❑ Gravel Pack F1Tracyt Type of Casing Specifications r Public F1 Other ^V ❑ Delta Depth of Grout Seal Type of Grout—.--- I rout -_I 1 Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump Sv H.P. i ' State.Work Done 42LZZ O lneemf Well Destruction ❑ Well Diameter Sealing Material stop 501 Depth ' ` Filler Material (Below 50'1 — TYPE OF SEPTIC WORK: NEW-.INSTALLATION 1.1—REPAIR/ADDITION i I ,DESTRUCTION l 1 INo septic system permitted if public sewer is ' available within 200 feet.) S Installation will serve: Residence Commercial_ Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: t Water table depth SEPTIC TANK ❑ Type/Mfg Capacity ' s No. Compartments PKG. TREATMENT PLT- ❑ � .. r ". Method of Disposal O Distance to nearest: Well Foundation—" Property Line LEACHING LINE ❑ No. & Length of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS i I Depth Size — Number SUMPS Cl Distance to nearest: Well Foundation Property Line O —"—DISPOSAL-PONDS•— x❑ =:» hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for . h this permit is issued,1 shall employ persons subject to workman's compensa- tion laws of California." The applic mu r uired inspections. Comple drawing o arse side. Signed date: /�✓ FOR DEPARTMENT USE ONLY / Application Accepted by Date At�n Area l Pit or Grout Inspection by Date Final Inspection byJ' Date Additional Comments: ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 r� FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. ! INFO CASH +.EH 13-24(REV.I/n 5) ->s,Vv C `2&-rte &11—a3316 EH 14-26